Provider Demographics
NPI:1245575398
Name:FABULOUS SMILES OF MESA
Entity Type:Organization
Organization Name:FABULOUS SMILES OF MESA
Other - Org Name:FABULOUS SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:HYUNG
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-654-3000
Mailing Address - Street 1:4434 E. BROWN RD.
Mailing Address - Street 2:STE 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205
Mailing Address - Country:US
Mailing Address - Phone:480-654-3000
Mailing Address - Fax:480-654-0303
Practice Address - Street 1:4434 E. BROWN RD
Practice Address - Street 2:STE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205
Practice Address - Country:US
Practice Address - Phone:480-654-3000
Practice Address - Fax:480-654-0303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FABULOUS DENTAL MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ83581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty